Learn the Art of Observation
The whole art of medicine is in observation… but to educate the eye to see, the ear to hear and the finger to feel takes time, and to make a beginning, to start a man on the right path, is all that you can do.William Osler. “The Hospital as a College” Aequanimitas. 1914:332
One of my favourite books as a medical student was Michael Zatouroff’s Physical Signs in General Medicine, a book brimming with weird and wonderful illustrations of humankind’s myriad afflictions. The book begins with an important lesson.
The very first photograph is a spider web bejeweled with drops of dew, much like the photograph below.
What can you see?
…so what do you see?
You see a spider web. Each thread is lined by drops of dew. Look more closely at the drops of dew – now what can be seen?
Through the lens of each dew drop we can see a horizon with sky above and the earth below. This is an interesting observation because a convex lens – like each of these drops of dew – inverts images.
So now what can we see?
An upside down photograph of a spider web lined with drops of dew.
To see this we need to know that drops of dew have the properties of a convex lens and that a convex lens inverts an image. Indeed, we can only see what we know — what we have been taught to see.
Many great medical teachers through the ages have emphasized the paramount importance of the art of observation. Chief among these were Joseph Bell – the Edinburgh surgeon who inspired the creation of Sherlock Holmes – and, of course, the immortal William Osler. I’m sure you’ll agree that Joe Bell’s lesson on the art of observation is one that should never be forgotten..
Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert.Thayer WS quotes Osler in “Osler the Teacher” Johns Hopkins Bulletin 1919:XXX;198
Yet learning the art of observation is difficult, and may seem an insurmountable task to the novice. Osler well knew the size of this challenge, and he encourages us from the past to persist. Only by observing countless patients over many years can we learn to truly see, and our mastery will grow until the day we each hang up our stethoscopes. Yet, no matter how feeble and immature our talents of observation are, exercising them can reap unimaginable rewards.
Get the patient in a good light. Use your five senses. We miss more by not seeing than we do by not knowing. Always examine the back. Observe, record, tabulate, communicate.Abbott ME. of William Osler. The pathological collections of the late Sir William Osler at McGill University. Bulletin of the International Association of Medical Museums 1926;IX: 185-199
As a fledgling medical student I was sent to the emergency department to see a patient with pyelonephritis (a kidney infection) who had been referred to our team. The young woman was an immigrant from South Asia and the mother of two small children. Her presenting complaints were loin pain and fever, and her urine sample was full of white cells — a a presentation entirely consistent with the diagnosis of pyelonephritis. Being an ignorant medical student fearful of missing something obvious, I asked her to expose her back so that I could see where she was tender. I knew little of medicine but it struck me that a visibly discoloured area, markedly tender and boggy to the touch, was not typical of pyelonephritis. Disturbed by this unexpected discovery, I asked my registrar to come see the patient immediately. One glance from the experienced eyes of the registrar led to an urgent surgical consult and the opening of operating theatre doors. The patient lived, thanks to the removal of a couple of kilograms of dead latissimus dorsi. Although I knew little, and had barely even heard of necrotizing fasciitis, by listening to Osler, I was able to see.
Medicine is learned by the bedside and not in the classroom. Let not your concepts of the manifestations of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first. No two eyes see the same thing. No two mirrors give forth the same reflection. Let your word be your slave and not your master.Thayer WS quotes Osler in “Osler the Teacher” Johns Hopkins Bulletin 1919:XXX;198
Of course, not only doctors, but patients may also benefit from strengthening their powers of observation…
LITFL Further Reading
- Lessons from Osler 001 – Work, the Master Word in medicine
- Lessons from Osler 002 – Fun and a sense of humor
- Lessons from Osler 003 – The art of observation
- Lessons from Osler 004 – Treat the patient, not the disease
- Lessons from Osler 005 – Why examinations are necessary
- William Osler: Oslerisms
- Sir William Osler (1849 – 1919) the history of Osler nodes and ephemeral Oslerisms
the person behind the name
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.